Palliative Care and the Management of Dyspnea

Assessment of Dyspnea

One of the APN's clinical activities should include a comprehensive assessment of the patient with dyspnea. Similar to pain, dyspnea is subjective, so the patient's self report remains the foundation for the assessment whenever possible. Many of the parameters used to assess pain are also used in the assessment of dyspnea,^[22] including:

Onset of symptom (acute vs chronic)
Frequency (hourly, daily, a few times per week, only when walking, etc)
Severity (currently, at its least, and at its worst, using an appropriate scale such as the Visual Analog Scale (VAS) or Borg -- see below)
Any associated symptoms (eg, cough, dizziness)
Exacerbating or alleviating factors (both pharmacologic and nonpharmacologic)
Impact on mood, activities of daily life, ability to sleep and eat
Meaning of symptom
Concerns about specific therapeutic interventions (ie, opioid analgesics and potential for substance abuse or respiratory depression)
Past and current treatments (including primary treatments for malignancy, over-the-counter medications, herbal supplements, etc) as well as dosing schedule, patient adherence, and side effects

The VAS, which is a valid and reliable tool, assesses symptom intensity by using a 100-mm line that can be either vertical or horizontal. Word anchors are attached to each end of the line to indicate the extremes of the sensation, with 0 representing "no breathlessness" and 100 representing "worst possible breathlessness." The patient places a mark along the line to correspond with his or her symptom intensity, and the clinician then measures the distance from the bottom of the scale (vertical) or from the left (horizontal) to the patient's mark.^[1]

The modified Borg scale is a 10-point scale with descriptors anchoring the ends and specific numbers listed within the scale; it provides a valid and reliable alternative for evaluation of dyspnea severity.^[23]

Most important, the APN should choose an assessment tool that the patient is able to understand, and then implement it consistently.

The APN also should be mindful of the need to clarify the language and words that patients use to describe dyspnea. Patients may use word descriptors differently due to the underlying cause of dyspnea or due to his or her cultural or ethnic background. Depending upon how the APN solicits patient responses, these variables can cause misunderstandings and lead to under-reporting and inadequate symptom management.^[24,25,26]

In addition to symptom assessment, the APN must evaluate and obtain other clinical information from the patient and family in order to arrive at an appropriate treatment plan.^{[27,28,29,30]} This subjective and objective information includes:

Past medical history
Physical examination, which may include use of accessory muscles, presence of dullness to percussion, decreased tactile fremitus, absent breath sounds, adventitious breath sounds, elevated jugular venous pressure, audible third heart sound (S3) or distant heart sounds, and pulsus paradoxus
Diagnostic studies such as complete blood count (CBC), serum electrolytes, chest x-ray, CT scan of chest, pulmonary function tests, sputum/bronchial cultures, arterial blood gases, blood natriuretic peptide, d-dimer, and oxygen saturation level (if appropriate to goals of care)
Social history
Smoking history
Advance directives, such as a healthcare proxy, living will, and wishes related to resuscitation and intubation
Psychological assessment, including mental status, presence and/or history of anxiety, coping styles of patient and family, meaning of symptom to patient and caregivers
Environmental assessment, such as the use of oxygen, need to climb stairs, distance to toilet, room temperature, air quality, appropriate use of medications, and stress of caregivers

Cite this: The Advanced Practice Nurse's Role in Palliative Care and the Management of Dyspnea - Medscape - Dec 31, 2006.

Etiology of Dyspnea ^[1,15,16]
Physiologic System	Disorder
Pulmonary	Asthma
	Adult respiratory syndrome
	Bronchial obstruction
	COPD (bronchitis, emphysema)
	Cystic fibrosis
	Interstitial lung disease
	Lung cancer
	Patient/ventilatory asynchrony
	Pleural effusion
	Pneumonia
	Pneumothorax
	Pulmonary embolism
	Chemotherapy toxicity
	Chest wall fractures related to metastatic disease
Cardiovascular	Congestive heart failure
	Fluid overload
	Superior vena cava syndrome
	Arrhythmias
	Cardiomyopathies
	Valvular or pericardial disease
	Congenital abnormalities
	Chemotherapy toxicity
Hematologic/Metabolic	Anemia
Hematologic/Metabolic	Electrolyte abnormalities
Neuromuscular	ALS
	Muscular dystrophy
	Multiple sclerosis
	Myasthenia gravis
	Reduced respiratory muscle force (deconditioning)
Psychological/Spiritual	Anxiety
	Depression
	Spiritual distress

ALS = amyotrophic lateral sclerosis; COPD = chronic obstructive pulmonary disease.

Scheduling of Opioids for the Management of Dyspnea ^{[1,41,60,80,81]}
	Opioid Naive*	Opioid Tolerant*
Mild dyspnea	Hydrocodone (5 to 10 mg) or codeine (30 mg) orally every 4 hours	Increase dose by 25% to 50%
Severe dyspnea	Morphine sulfate 5 mg orally every 4 hours, or oxycodone 5 mg orally every 4 hours, or hydromorphone 1 mg orally every 4 hours	Increase dose by 25% to 50%
Severe dyspnea	Parenteral morphine 2.5-5.0 mg subcutaneously or intravenously every 3-4 hours	Increase dose by 25% to 50%
Titration	Increase orally by increments of 50% to 100% every 24 hours as needed; titrate parenterally to effect	Increase by increments of 50% to 100% every 24 hours as needed

*If a patient is elderly or has severe pulmonary disease, such as COPD, start at 50% of the above doses and titrate more conservatively with increments of 25%. If the patient requires frequent dosing, the 24-hour total can be calculated and then converted into a sustained-release preparation, with the availability of a short-acting breakthrough dose every 2 hours as needed.

Benzodiazepine Therapy for the Management of Dyspnea ^[1,24]
Benzodiazepine	Dosage and Titration
Short-acting Formulations
Lorazepam	Starting dose: 0.5 to 1.0 mg orally every hour until the symptom is controlled, with routine dosing every 4-6 hours thereafter
Midazolam	Starting dose: 0.5mg IV every 15 minutes until dyspnea is controlled, then maintenance of a continuous subcutaneous or intravenous infusion
Long-acting Formulations
Diazepam	Starting dose: 2-10 mg orally every hour, then routinely every 6-8 hours
Clonazepam	Starting dose: 0.25-2.0 mg orally every 12 hours

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